“Covered Benefit” Does Not Mean It’s A Benefit That Will Be Covered
Perhaps you might have wondered why I don’t blog so much lately. That would be because my full-time job these days is navigating the The Best Health Insurance System In The World!TM on behalf of my elderly mother.
You may recall that a few weeks back, her wallet was stolen, necessitating cancellation of her existing Blue Cross insurance number and issue of a new number and card. If you will recall, I explained that it appeared to providers in the interim as if my mother had no coverage.
Well, I finally received the new card with the new number. I spent a good deal of time this morning calling health care providers who had provided services to my mother during the interim period, to let them know what the new card number was so they could proceed with billing. We got the new card just in time, I thought – for as bad luck would have it, mom had another health care emergency today, and is in the ER as I type. My brother and sister-in-law are with her, and I gave them the new health care number to use at the hospital. I’m waiting for reports from them on how mom is doing.
And then I went out for a quick lunch, to get out of the house and decompress for a bit.
Upon returning home, I found a phone message from one of the providers I’d called in the morning. You guessed it: problems in dealing with the health insurance company.
The provider, a pharmacy that had dispensed a medication my mother needed for short term treatment, had spent one hour on the phone arguing with the health insurance company that the new number was valid and that my mother did, indeed, exist in the health care system. The insurance company was sure that she did not. I called the insurance company; they claimed there was no record of the provider calling to inquire about coverage for my mother.
At this point it was near 5 pm and the pharmacy and I agreed to give up for today and start again tomorrow. Part of what we think is going on is that coverage for medications is handled by a separate wing of the health insurance company, and they apparently have not yet gotten the information that my mother still has coverage. This, of course, begs the question as to why she ever had to be labeled as not having coverage in the first place. I mean, presumably you could invalidate an insurance number without invalidating a person covered on a policy, no? It seems to me that should be technically possible.
The very nice person at the pharmacy trying to help me navigate this maze and get my mother’s prescription paid for was very sympathetic to me when I said, “this is basically my full time job. This is what I do all day – deal with the health insurance issues of my mother. What do people do when they don’t have someone to help them out with this? Or how do they do it when they have to work all day and can’t spend all day on the phone chasing down this stuff?” She said, “This is why people go broke. They don’t have someone to help them sort through the problems and roadblocks, and they end up paying for bills they shouldn’t have to pay for. And there are so many roadblocks – and they are put there for a reason.” By now, she and I have collectively spent in time dealing with the health insurance company way more than the $140 worth of medication that was dispensed to my mother.
I have a friend who pays cash for Singulair allergy medicine ($5 per tablet) instead of the co-pay price ($0.50 per tablet) because after three hours on the phone trying to obtain authorization, he just gave up. He doesn’t use the medication on a daily basis, so he can afford to absorb the price.
But see, that’s exactly what they count on. They count on most people giving up in frustration, out of lack of time to deal with the inanities and roadblocks and frustrations and “we lost your claim, you’ll have to refile it” or maybe they just die while they are waiting for their case to wend its way through the system. People give up because they don’t know how to deal with the roadblocks, they don’t have time, they get beaten down by the sheer frustration of it, the impersonality of it. You can never talk to the same person twice, every time you call you have to repeat all the facts of your case from square one all over again. You think, how can it be worth it for them to spend three hours keeping me from getting my Singulair? But it isn’t just you, it’s everyone, and if 95% of the people give up, they just don’t have to pay for that “covered benefit”. That’s how they can afford these buildings to intimidate you with when you come downtown to argue your appeal case for your coverage. That’s how the fantastic salaries for their CEOs are made – every goddamned dollar of them earned through your frustration, your conclusion that it is easier to pay the $5 a tablet for Singulair than to spend who knows how many hours it will take on the phone to get your coverage – an argument you may have to go through not just once, but repeatedly.
I appealed for coverage for my botox treatments for my migraines, because absolutely nothing else works to prevent them, and because having had a stroke, most common prescription meds for treating migraines are contraindicated for me. And I had data showing that botox treatments actually worked. I went through three levels of appeal. I went to that fancy building downtown for a hearing. I prepared what amounted to a mini-clinical study report on myself, in a three-ring binder, complete with literature references, and handed it out to the appeals panel members. I convinced them to approve my treatment. I have a letter from them stating that I have approval to receive this treatment for my migraines. Yet, nearly every time I receive a treatment, I also get an “explanation of benefits” form (there’s an oxymoron if I’ve ever heard one) saying that coverage is rejected because the treatment is not a covered benefit. At which point I have to get on the phone, explain that I do have permission for coverage, and ask them to refile. At which point, inevitably, the person I am talking with says, “oh yes, I can see your letter of permission right here in your file.” So, you know, it’s not like it was hard to find. It’s not like they’ve never been through this before. It’s not like the person who first processed this instance didn’t know it was there or couldn’t find it. They just reject the damn thing hoping that this time, I’ll give up, and they won’t have to pay this one, and maybe never have to pay again.
Don’t talk to me about government-instituted “death panels”. The real death panels are the ones in that building in downtown Philadelphia, and similar ones belonging to other health insurance companies around the nation. The ones who attempt to stymie you at every turn in your efforts to access your “covered benefits”. The ones who hope you will give up, go away, or die before they ever have to get around to paying anything on any of your claims.